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Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Heart Team for Left Atrial Appendage Occlusion: A Patient-Tailored Approach
Stefano Branzoli1,2, Fabrizio Guarracini3, Massimiliano Marini3
1Department of Cardiac Surgery, UZ Brussel, Av. du Laerbeek 101, 1090 Brussels, Belgium.
Insights
A heart team approach aids decisions for left atrial appendage occlusion (LAAO) to prevent stroke. Both percutaneous and thoracoscopic LAAO are safe and effective, with thoracoscopic potentially better for high-bleed-risk patients.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Left atrial appendage occlusion (LAAO) is a stroke prevention strategy.
- The optimal LAAO technique and device remain undetermined.
- A heart team approach can personalize LAAO decision-making.
Purpose of the Study:
- To evaluate the role of a heart team in LAAO decision-making.
- To compare percutaneous versus thoracoscopic LAAO in patients contraindicated for anticoagulants.
- To optimize risk-benefit in patient-centered LAAO choices.
Main Methods:
- Forty patients were evaluated by a heart team for LAAO.
- Key variables included CHA2DS2VASc, HAS-BLED, comorbidities, and patient quality of life.
- Twenty patients underwent percutaneous LAAO, and twenty underwent thoracoscopic LAAO.
Main Results:
- Procedure duration and hospital stay were similar for both groups.
- Complete appendage exclusion was achieved in all patients.
- No neurological or hemorrhagic events occurred during a mean follow-up of 33.1 months.
Conclusions:
- A heart team approach enhances LAAO decision-making for stroke and hemorrhage prevention.
- Percutaneous and thoracoscopic LAAO demonstrate comparable safety and efficacy.
- Epicardial LAAO may be preferred for patients at high risk of bleeding post-procedure.
Background And Purpose:
Left atrial appendage occlusion (LAAO) is an accepted therapeutic option for stroke prevention; however, the ideal technique and device have not yet been identified. In this study we evaluate the potential role of a heart team approach for patients contraindicated for oral anticoagulants and indicated for left atrial appendage closure, to minimize risk and optimize benefit in a patient-centered decision-making process.
Methods:
Forty patients were evaluated by the heart team for appendage occlusion. Variables considered were CHA2DS2VASc, HASBLED, documented blood transfusions, comorbidities, event forcing anticoagulant interruption, past medical history, anatomy of the left atrial appendage, and patient quality of life. Twenty patients had their appendage occluded percutaneously (65% male, mean age 72.3 ± 7.5, mean CHA2DS2VASc 4.2 ± 1.5, mean HASBLED 3.5 ± 1.1). The other twenty underwent thoracoscopic occlusion (65% male, mean age of 74.9 ± 8, mean CHA2DS2VASc 6.0 ± 1.5, HASBLED mean 5.4 ± 1.4). Percutaneous patients were on dual antiplatelet therapy for the first three months and aspirin thereafter, whereas the others received no anticoagulant/antiplatelet therapy from the day of surgery. Follow up included TEE, CT scan, and periodical clinical evaluation.
Results:
Mean duration of procedures and hospital stay were comparable. All patients had complete exclusion of the appendage; at a mean follow up of 33.1 ± 14.1 months, no neurological or hemorrhagic events were reported.
Conclusions:
A heart team approach may improve the decision-making process for stroke and hemorrhage prevention, where LAAO is a therapeutic option. Percutaneous and thoracoscopic appendage occlusion seem to be comparably safe and effective. An epicardial LAAO could be advisable in patients for whom the risk of bleeding is estimated as being too high for post-procedural antiplatelet therapy.
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